COPENHAGEN

DIABETES PREVALENCE IN COPENHAGEN,
2017–2045 (ADULTS AGED 20–79)

If we reduce obesity by 25.0% by 2045,
4,600 cases of type 2 diabetes can be avoided, and 33 million dollars
in healthcare expenditure saved

UNDERSTANDING THE COMPLEXITY OF VULNERABILITY

The Vulnerability Assessment reveals new knowledge about why some
people in Copenhagen are vulnerable to developing type 2 diabetes and
its complications, despite equal access to healthcare, preventive
services and healthy initiatives in the community. Furthermore, the
research reveals that diabetes is not the biggest concern in an
everyday life where other social and health issues are more predominant.

Various insights into why some people are vulnerable to type 2
diabetes and its complications have emerged from the research; some of
the most important are highlighted below.

Hierarchy of everyday issues

Vulnerability in Copenhagen is closely associated with the Danish
term ‘manglende overskud’, which translates as lack of energy. Several
issues in everyday life impact on people’s ability to focus on their
health, influencing their vulnerability to developing diabetes and
diabetes-related complications. Other social and health issues, such
as comorbidities, unemployment, financial difficulties, major life
events and loneliness, often influence people’s daily decisions,
leaving no energy to care for their health or even their diabetes.
Social and health issues are interlinked, and diabetes is not the
highest in the hierarchy of everyday issues.

The research indicates that people at risk of developing type 2
diabetes do not perceive diabetes as a severe health risk compared to
other diseases. Some perceive diabetes as a ‘healthy disease’ due to
the likelihood of being independent of medication if the condition is
managed well.

Sufficient knowledge

Lack of information and knowledge are often cited as key barriers to
people taking action in relation to diabetes. However, findings from
participants in Copenhagen challenge the notion that lack of knowledge
is a barrier to preventing diabetes and its complications. Insights
from the research indicate that people are aware of diabetes risk
factors and diabetes-related complications, and that they have
sufficient knowledge.

In addition, the majority of participants are unaware of the
prevention services available through the healthcare system. Based on
the research, people face different challenges in relation to
leveraging the healthcare system.

Often, to access healthcare services in Denmark, people require a
referral from a general practitioner (GP). The fact that GPs serve as
gatekeepers to information and services can act as a barrier to people
accessing preventive services such as community health centres. The
inconvenience of the procedure of requesting a referral means that
many people miss out on the benefits of available services.

Living alone and social support

Having a family is of great importance. People value regular
interaction with their family members as well as the feeling of being
loved and of importance. In the face of difficulties, relatives and
friends provide a support structure that people see as being essential
to their wellbeing. In the absence of social support, people can
experience difficulties with basic everyday tasks such as getting out
of bed in the morning or preparing a home-cooked meal.

Living alone was also an indicator of vulnerability in the research,
with a number of participants experiencing difficulties with being on
their own. Living alone can influence the participants’ ability to
take care of their own health. In general, many of the participants
find it unsatisfying to eat alone and, consequently, they do not
bother preparing a proper meal. Instead they end up choosing easy
solutions such as bread, frozen products or takeaways.

Participants also seem to be more motivated to participate in social
activities, physical exercise classes or attending the gym when they
have someone to join them.

THREE CASES FROM COPENHAGEN

Three cases that exemplify some of the key insights into
vulnerability to type 2 diabetes and its complications are presented here.

Meet Sanne

• 60 years old • Public health insurance •
Overweight • Early retirement due to cancer • Type 2
diabetes

Read Sanne’s story

About Sanne

Sanne is 60 years old and lives on her own in an apartment in the
district of Valby.

She was diagnosed with type 2 diabetes in 2005 and, as a result of
her diabetes, she has developed inflammation of the nerves in her
feet. Despite this, she says that: “Diabetes doesn’t take up much
thought in my everyday life. What matters the most is the pain
caused by my other conditions”. Besides type 2 diabetes, Sanne
suffers from bone marrow cancer (multiple myeloma), which causes her
intense pain every day. Consequently, she stays alone at home most of
the day due to her conditions.

When Sanne was first diagnosed with type 2 diabetes, she did not
take proper care of herself and her diabetes. Now she feels that she
must live with the consequences. As she puts it: “I’m well aware
that if my leg needs to be chopped off one day, then it’s probably
my own fault, right? It isn’t something that worries me – just a
part of my life”.

Her other diseases prevent her from exercising, and she does not
have any energy to cook proper meals for herself. She often tends to
go for easily prepared and less nutritious meals, such as bread with
cold cuts or ready-made meals from the supermarket. On days when she
is feeling particularly ill, she orders takeaways, although she
says: “I’m not the type who loves to go out and eat unhealthy
stuff, but on days when I feel very ill, I have to order food from
outside. That’s when my weight goes up – because of all that
deep-fried stuff”.

Apart from health professionals, Sanne does not see many people
during the day. Her friends and her sister visit her a couple of times
a year. When her friends are visiting, they do the cooking and they
take into account that she has diabetes.

Sanne and risk of diabetes complications

Sanne is aware of her risk of developing serious diabetes
complications. Because of her cancer, which causes her pain, she does
not have the energy to focus on her diabetes. This makes her extremely
vulnerable to getting serious fluctuations in blood sugar and complications.

Why is Sanne’s case interesting?

Sanne’s case demonstrates how multiple diseases can have enormous
implications for self-management of diabetes. It also highlights how
comorbidities can isolate a person in their home.

Meet Michael

• 51 years old • Public health insurance • Overweight

Read Michael’s story

About Michael

Michael is a 51-year-old unemployed man who lives together with his
39-year-old girlfriend, Anna, in a small house in Tingbjerg in the
district of Brønshøj/Husum.

They are both overweight, and Michael is aware of his risk of
developing diabetes, especially after Anne was diagnosed with type 2
diabetes a few months ago. He believes that the diagnosis will have a
positive and healthy effect on them, as they now have a reason to make
healthier choices.

However, on a daily basis he does not give it a lot of thought.
Being unemployed and a job-seeker takes up a lot of his time and
energy in his everyday life. Sometimes being unemployed gets too much
for him. When this happens, Michael’s motivation with regard to eating
healthier weakens, and he ends up using food as a comfort: “If
you’re having an emotional downturn because you have difficulties
finding a job, then somehow you eat more compulsively and maybe you
eat more than what’s good for you”.

He also believes that diabetes is ‘the healthiest disease’ because
you can become independent of insulin if you manage your diabetes
well: “It’s the healthiest disease because if you lose weight, the
disease will disappear”.

Both Michael and Anna would like to lose weight by participating in
physical exercise activities, but membership fees for the gym are
expensive. Some local exercise facilities are free of charge,
including an exercise class for women only. Both Anna and Michael
prefer activities where they are able to participate together or with
someone they know well to help keep them motivated.

“If we were to participate in an organised activity, then we would
have to participate together […]. The motivation is lacking when you
have to go alone”.

Michael and diabetes risk

Being overweight makes Michael feel at risk of developing diabetes.
However, he does not give it any thought during his everyday life, as
thinking about it makes it unbearable on top of all his other issues.

Why is Michael’s case interesting?

Michael’s case shows that being aware of one’s risk does not
necessarily translate into leading a healthy lifestyle. Issues in
everyday life, such as unemployment, may have a greater influence on
one’s mental and physical ability to make healthy choices.

Meet Karen

Karen is a 55-year-old woman who lives alone in the Tingbjerg and
has two grown-up children.

Karen was diagnosed with type 2 diabetes one year ago, but it has
not made a great impact on her everyday life as she does not
experience any physical signs of her condition. For this reason, Karen
has difficulty accepting her diagnosis.

In the past five years, she has lost several close family members,
and when the feeling of loss takes over, it becomes a challenge for
Karen to manage her diabetes. “I think about what I’m supposed to
eat and what I should avoid, and then sometimes it just doesn’t
matter when I’m sitting alone and thinking about life”, she says.

Karen’s GP wants her to lose weight, and Karen knows which lifestyle
changes she has to make, but she has difficulty transforming her
knowledge into action. As she puts it: “I hear the same story every
time: ’Mind your diet, mind your diet’, and then I say: ... of
course I know what I’m supposed to eat and what I’m not allowed to
eat, right?”

She does not enjoy cooking and eating alone. Consequently, she does
not cook hot meals for herself at home. Instead, she eats bread with
butter and cheese every day because it is easy to prepare. She
associates this kind of meal with quality of life. She is therefore
not willing to sacrifice this by eating something healthier. “You
have to feel alive”, she says. Her two grown-up sons are very
aware of their mother’s monotonous diet and invite her over for supper
at least once a week to make sure that she eats a cooked meal. They
also call her daily to ensure that she is alright and not engrossed in
depressive thoughts.

A few years ago, she was injured in a traffic accident and still
struggles to walk as a result. Currently, Karen is participating in a
free 12-week diabetes-exercise course offered by the local community
health centre. She enjoys this because she has the opportunity to
exercise with other people similar to herself, either with physical
limitations or large body size. She previously tried to attend a local
gym, but she never felt comfortable there among the slim young fitness
users and their condescending stares. “I wanted to do some
exercise, but I didn’t like going to the gym because I was
overweight. I have tried – but people stare as if there’s something
wrong with you”.

Karen is worried about becoming inactive again when the 12-week
course ends, as she knows that she will most likely not continue the
exercises at home on her own.

Karen and diabetes

Karen knows that her unhealthy lifestyle has consequences and that
it is one of the reasons why she has diabetes, but making drastic
lifestyle changes is just too difficult for her right now.
Transforming knowledge into action is difficult for her.

Why is Karen’s case interesting?

Karen’s case shows the importance of support from family and friends,
and how living alone can influence self-management of type 2 diabetes.

DIABETES CHALLENGE

Rule of Halves

In Copenhagen, the prevalence of diabetes is 5.1%. With respect to
the Rule of Halves, about one in four people with diabetes is unaware
of their condition, thus have not got a diagnosis. Despite the fact
that almost everybody who is diagnosed with diabetes receives care,
about half of those receiving care do not achieve treatment targets.
Lastly, 40% of those achieving treatment targets do not achieve the
desired outcomes – living a life free of diabetes-related complications4.

Despite the relatively low prevalence of diabetes in Copenhagen, the
research reveals that 10–20% of the population is at high risk of
developing type 2 diabetes4.

The risk of developing type 2 diabetes is especially elevated in two
districts of Copenhagen compared to the more affluent inner city area,
despite the close proximity of only 7 km4.

Research reveals that there are major socioeconomic differences in
the prevalence of type 2 diabetes and the risk of developing it in
Copenhagen. Citizens with low levels of education have twice the
prevalence of high-risk scores and diabetes compared to citizens with
higher levels of education, the rate of high-risk scores and diabetes
among citizens not employed is significantly higher than that among
employed citizens of the same age, and populations with a non-western
background have twice the prevalence of diabetes compared to
populations with a western background.4

The Rule of Halves research was conducted based on existing
quantitative data from registries and surveys. Findings were used to
identify locations and define profiles as a basis for the qualitative
research. Two ‘high-risk’ locations were defined through the
quantitative research.

Qualitative research

The two ‘high-risk’ locations Brønshøj/Husum and Valby served as a
basis for recruiting participants for the qualitative vulnerability
assessment. People at increased risk of developing type 2 diabetes or
with existing diabetes were identified. All participants matched at
least two of the following factors: male gender, over 45 years of age,
short education, unemployed, BMI >30, non-western background and
cohabitation status (living alone). In total, 24 citizens at risk and
26 people with type 2 diabetes were interviewed by trained
fieldworkers in their homes.